Public Health

Ambulance response time can vary widely across cities, depending on traffic patterns and the location of the emergency situation. As a volunteer medic in Jerusalem, Elli Beer witnessed firsthand how a few minutes can make a significant difference in saving a life. His frustration with poor ambulance response times led him to develop an all-volunteer rescue service called United Hatzalah.

In this recently posted TEDMED talk, Beer talks passionately about how a small neighborhood group dedicated to responding to nearby emergencies evolved into United Hatzalah’s network of 2,000 volunteers. Today, volunteers respond to incidents on “ambu-cycles,” motorcycles carrying the same equipment as a conventional ambulance but lacking the ability to transport patients, and have treated more than 200,000 people in the past year. Beer has rolled out the service in Brazil and Panama and plans to expand to India.

Previously: Comparing the cost-effectiveness of helicopter transport and ambulances for trauma victims and On using social media to improve emergency-preparedness efforts

In an unusual collaboration, officials from the health-care and nuclear industries met last July to discuss each field’s similarities and differences between four topic areas, including diagnostic and prognostic technologies and human factors that affect risk and reliability. The Association for the Advancement of Medical Instrumentation recently released a 120-page monograph detailing the lessons learned during the tw0-day workshop.

Today’s issue of Inside Stanford Medicine includes a Q&A with David Gaba, MD, professor of anesthesia and the associate dean for immersive and simulation-based learning at the School of Medicine, discussing his participation in last year’s meeting and what health-care providers can learn from the nuclear industry. He says:

One big one is the need for standard operating procedures, where possible, which also retain flexibility as needed. A major spinoff of this principle, used extensively in nuclear power, is to provide graphically enhanced written protocols for emergency situations. It is long recognized that nuclear power operators cannot remember everything they need to know in managing an adverse event in a nuclear plant — memory is too fallible. Thus, the use of written procedures is a mainstay in this setting. Health care has long depended largely on the individual skill and memory of physicians and nurses. Protocols and checklists or emergency manuals were decried as cheat sheets or cribs. We now know that the best people use these kinds of supports — not because they are stupid but because that is the best way to get the best results in tough situations. My lab and other colleagues at Stanford have been working for some time on written cognitive aids and emergency manuals for anesthesia professionals. These have now been disseminated to all the anesthetizing locations in Stanford’s hospitals and those of its close affiliates. This lesson has clearly come from the nuclear industry and from others such as aviation.

Another lesson from the nuclear industry is the importance of the safety culture in an organization. When the organization favors throughput so heavily that people cut corners on safety, or when personnel are afraid to speak up when they see something unsafe, the risk climbs.

Something near and dear to my heart is the utility of simulation for training of skilled professionals. My lab’s development of simulators and simulation-based curricula in health care was triggered by knowing a little bit about how they are used in aviation and other industries like nuclear power. But I actually had no idea, until this workshop, just how much simulation is required for nuclear power operators. They spend six weeks doing their usual shifts in the control room, and the seventh week is spent in training simulations. All year round, no matter how much prior experience they have. Health care is just scratching the surface in simulation compared to that, but at least we have started our way down a similar road.

Previously: Sully Sullenberger talks about patient safety

Past research suggests that poor sleep during adolescence can have “lasting consequences” on the brain. Now a new study offers additional insights into the negative health effects of sleep deprivation on teens’ health.

In the study, researchers analyzed data collected from more than 10,000 adolescents as part of the National Comorbidity Survey Adolescent Supplement. As MedPage Today reports, their findings show that prolonged fatigue is associated with mood and anxiety disorders among teens:

In a nationally representative sample of adolescents ages 13 to 18, 3% reported having extreme fatigue lasting at least 3 months and about half of those who did also had mood or anxiety disorders, according to Kathleen Merikangas, PhD, of the National Institute of Mental Health in Bethesda, Md., and colleagues.

Having both prolonged fatigue and a mood or anxiety disorder was associated with poorer physical and mental health and greater use of healthcare services compared with having only one of the disorders, the researchers reported online in the American Journal of Psychiatry.

“This suggests that the presence of fatigue may be used in clinical practice as an indicator of a more severe depressive or anxiety disorder,” Merikangas and colleagues wrote.

Stanford physician Michelle Primeau, MD, recently explored the topic of how teen sleep habits affect mood in a recent Stanford Center for Sleep Sciences and Medicine blog entry on the Huffington Post. In her post, she explains why teens in particular are at risk of chronic partial sleep deprivation:

Teenagers need to sleep about nine hours, and as they get older, they tend to sleep less. This is not because they need less, but because they are busier with school, jobs, extracurricular activities, and friends. Their biology also will often shift so that they tend to fall asleep later and want to sleep in later, an occurrence that may represent delayed sleep phase syndrome. This may explains why your teenager is so hard to wake up on Saturdays. But this shift to a later bedtime, both of social and biologic causes, in combination with fixed early school times, means that many teenagers are walking around sleep deprived.

Previously: Can sleep help prevent sports injuries in teens?, Study shows link between lack of sleep and obesity in teen boys, Study shows lack of sleep during adolescence may have “lasting consequences” on the brain, Teens and sleep: A Q&A, Sleep deprivation may increase young adults’ risk of mental distress, obesity, Districts pushing back bells for the sake of teens’ sleep and Lack of sleep may be harmful to a teen’s well-being
Photo by lunchtimemama

When we think of the AIDS epidemic, many of us turn to the developing world, overlooking the fact that HIV is very much a problem here in the United States. Every year some 50,000 people in this country are newly diagnosed with HIV, and many of these individuals previously had no idea they were infected with the virus.

To help prevent further spread of the disease, which affects an estimated 1.2 million Americans, the U.S. Preventive Services Task Force has issued (.pdf) a final recommendation that every adult between 15 and 65 be screened for the virus. Younger adolescents and older adults considered at risk also should be screened, as well as all pregnant women in labor whose HIV status is not known, the task force suggests.

“Treatment for HIV has advanced remarkably, helping people live longer and healthier lives, and reducing HIV transmission,” Stanford professor Douglas K. Owens, MD, one of the members of the task force, told me last week. “Treatment is most effective when offered early in the course of HIV disease, typically well before people have symptoms, and screening enables people to learn they have HIV in time to get the full benefit from treatment.”

“Screening is especially important because up to quarter of people who have HIV do not know they have it,” Owens added.

Studies have shown that people who are infected with the virus are significantly less likely to pass it along if they are receiving ARV treatment, which reduces the amount of virus circulating in the blood. Moreover, people who are infected are more likely to do better - suffering fewer opportunistic infections - if they receive treatment early on, rather than wait until symptoms occur and the disease becomes more advanced. For these reasons, identifying infected individuals through universal screening makes good public health sense.

The task force’s latest recommendation, published in the new issue of the Annals of Internal Medicine, is in keeping with the guidelines of the American College of Physicians, the American Academy of Pediatrics and the federal Centers for Disease Control and Prevention. Owens talked more about this issue with me last fall, after the task force’s draft recommendations were released.

Previously: Stanford expert discusses recommendation for universal HIV screening, Task force issues draft recommendation for universal HIV screening and National HIV screening and testing could be very cost-effective

Society is increasingly becoming more data-driven. Noting the power of vast reservoirs of public information, the federal government launched the Big Data Research and Development Initiative — a $200 million commitment to “greatly improve the tools and techniques needed to access, organize and glean discoveries from huge volumes of digital data.” And the National Institutes of Health expanded its stake in the federal initiative in hopes of speeding up the translation of biomedical discoveries into bedside applications.

In an effort to bring together innovative thinkers from information-technology corporations, startups, venture-capital firms and academia to capitalize on the wealth of opportunities using data-mining in biomedicine, Stanford Medicine and Oxford University are sponsoring a three-day conference from May 22-24. Curious to know more about the event and promise of big data, I reached out to Atul Butte, MD, PhD, Stanford systems-medicine chief and the conference’s scientific program committee chair. Below he shares why he’s passionate about how data-mining can transform scientific research and health care and discusses the conference program.

A recent Stanford Medicine article called data-mining the “fastest, least costly, most effective path to improving people’s health” that you know. Can you explain why you believe this to be the case?

Data-driven science, or data-mining, works faster and effectively because we are already sitting on billions of measurements made across the health system! Every time a physician orders a medication, every time a nurse or pharmacist dispenses a drug, every time a blood test is performed, every x-ray or CT scan that’s performed… all of this information ends up in a database today. So the part of science or innovation that involves collecting the measurements is actually the easiest part now, because the measurements are already there, just waiting for the right question to be asked.

In the same article, you said “hiding within [existing] mounds of data is knowledge that could change the life of a patient, or change the world” - and that if you didn’t analyze those data or show others how to, you feared no one will. How did you grow so passionate about this area?

I think we in the biomedical field make these measurements, but we often don’t realize how these measurements can interrelate or be used together. Our example from one of our recent articles was on our use of two big sets of public data. One set covered the molecular changes seen in tissues affected by diseases, and another set covered the molecular changes seen in cells treated by drugs. We realized that we could partner just these two public data sets together, to get new ideas of what other diseases might be treatable by these drugs. And, we could do this in a purely computational approach – an approach that is nearly infinitely scalable to more diseases, more investigators and more ideas. When I see hard working investigators working tirelessly to make highly accurate and significant measurements, but so few people taking advantage of that data, I can’t help but be passionate!

Earlier this year, you published a study, which involved combing through large amounts of data, to find that beta carotene may protect people with a common genetic risk factor for type-2 diabetes. Can you describe other recent findings that have stemmed from researchers’ use of this “big data” approach?

Stanford professor Russ Altman, MD, PhD, and his team recently showed how search engine logs can be mined to discover side effect of release drugs that might not have shown up during the initial clinical trials on those drugs. Similarly, Nigam Shah, MBBS, PhD, assistant professor of medicine, showed how similar side effects for drugs are sitting in physician clinical notes. Both text-based clinical notes and search engine logs are massive sources of big data that to date have barely been tapped for medical research.

What was the catalyst for launching the Big Data in Biomedicine conference?

The Li Ka Shing Foundation has played the leading role in bringing us together with Oxford University in planning events on big data. Our first, smaller conference was held in Oxford last November. Based on the success of that event, we realized we could host a larger conference at Stanford and open it up to the public. We couldn’t have done this without the support of the Li Ka Shing Foundation.

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Emergency helicopter transport can be pricey and, as recent reports of aircraft crashes show, potentially dangerous. Such downsides have sparked some concerns that transporting trauma patients by air may not be worth the risk. So researchers at Stanford set out to investigate how often medical helicopters needed to help save critically injured patients’ lives in order to be considered cost-effective when compared with ambulances.

Researchers published their findings (subscription required) online this month in the Annals of Emergency Medicine. My colleague explains their results in a release:

The researchers found that if an additional 1.6 percent of seriously injured patients survive after being transported by helicopter from the scene of injury to a level-1 or level-2 trauma center, then such transport should be considered cost-effective. In other words, if 90 percent of seriously injured trauma victims survive with the help of ground transport, 91.6 need to survive with the help of helicopter transport for it to be considered cost-effective.

The study… does not address whether most helicopter transport actually meets the additional 1.6 percent survivorship threshold.

“What we aimed to do is reduce the uncertainty about the factors that drive the cost-effective use of this important critical care resource,” said the study’s lead author, M. Kit Delgado, MD, MS, an instructor in the Division of Emergency Medicine. “The goal is to continue to save the lives of those who need air transport, but spare flight personnel the additional risks of flying - and patients with minor injuries the additional cost - when helicopter transport is not likely to be cost-effective.” (Helicopter medical services generally bill patients’ insurance providers directly, but patients may have to pay some of the bill out of pocket, or, if they’re uninsured, possibly all of it.)

The findings only apply to situations and locations where patients could be taken by both ambulance and helicopter to a trauma center. Researchers said that in scenarios where ground transportation to a trauma center wasn’t feasible, then transport by helicopter was preferable.

Photo by Brett Neilson

My best friend finally succeeded in his efforts to stop smoking when he experienced a highly motivating life change: Fatherhood. Likewise, many women discover that wanting to have a safe and healthy pregnancy gives them unprecedented desire to kick their tobacco habit. Knowing the research and clinical evidence may be useful to parents-to-be who have some questions about smoking:

1. Quitting smoking is very hard – does it really make enough difference to be worth it? Yes. To get one sense of the impact of smoking on fetal development, recall the widespread panic in the 1980s about “crack cocaine babies.” Subsequent research has shown that the damage to fetuses of cigarette smoking is in fact worse than that of crack cocaine use. Even if it didn’t benefit the fetus (and later, the infant) for a mother to quit smoking, it would still be worth using the extra motivation to quit that pregnancy provides for the sake of the mother’s long term health.
2. When is the best time to try to quit? Early. In an excellent lecture I saw last week, Professor Zachary Stowe, MD, with the University of Arkansas for Medical Sciences, pointed out that the soonest a woman can know she is pregnant is 4-6 weeks after conception, at which point fetal organogenesis is well underway. Further, Stowe and other researchers have conducted research identifying nicotine and its metabolites in the fetal compartment even after the mother has stopped smoking. Dr. Stowe therefore suggests that rather than waiting to quit until after stopping birth control or after pregnancy has been confirmed by a test, a mother-to-be should wait two weeks after quitting smoking before going off birth control. Note: Even if you didn’t do this, quitting smoking at any point later in the pregnancy is still good for the fetus (and for you too).
3. I smoke, but I’m not carrying the baby, so why does it matter whether I quit? This isn’t just about mom. Passively absorbed smoke contributes to nicotine in the fetal compartment, meaning that even if the mother quits, smoking by her partner may affect the fetus. Also, an added benefit to a couple of quitting together is suggested by research and clinical experience in addiction treatment: Relapse is more likely when the visible, auditory and olfactory cues of substance use remain in the environment. Hence, a mom-to-be is going to have a much harder time quitting cigarettes if her partner remains a smoker. More positively, if two people quit together they can remove those cues from the environment and also have built-in social support for resisting the cravings they both may experience.
4. Where can we get help with smoking cessation? Free resources are just a click away here. If you need extra support, consult your physician, who can help you both with smoking cessation and with other conditions you may have (e.g., depression) that make it hard to quit.

Addiction expert Keith Humphreys, PhD, is a professor of psychiatry and behavioral sciences at Stanford and a career research scientist at the Palo Alto VA. He recently completed a one-year stint as a senior advisor in the Office of National Drug Control Policy in Washington.

Previously: Craving a cigarette but trying to quit? A supportive text message might help, Exercise may help smokers kick the nicotine habit and remain smoke-free, Kicking the smoking habit for good and Can daily texts help smokers kick their nicotine addiction?
Photo by YOUscription

The number of gene-expression data sets available in public databases has climbed rapidly over the past decade, allowing researchers to spot disease trends without doing time-intensive experiments in the laboratory. The “big data” deluge promises to accelerate the process of understanding disease while driving down the costs of developing new therapies.

To underscore the wealth of opportunities for scientists who can mine these continuously growing databases in innovative ways, Stanford Medicine and Oxford University are sponsoring a three-day conference next month on big data’s role in biomedicine. The event will be held May 22-24 at the School of Medicine’s Li Ka Shing Center for Learning & Knowledge and will feature keynote speeches from Anne Wojcicki, CEO and co-founder of the consumer-genomics company 23andMe, and David Ewing Duncan, author of Experimental Man. In addition, attendees will hear from more than two dozen speakers representing large information-technology corporations, startups, venture-capital firms and academia.

In a release, Stanford systems-medicine chief Atul Butte, MD, PhD, who is the conference’s scientific program committee chair, commented on the motivation for hosting the conference and what participants will learn at the event:

We’re bringing together people from academia, industry, government and foundations who want to learn more about how big data can drive innovation for a healthier world… We expect that attendees will walk away from this with a strong understanding of the latest tools and technologies available for studying and using big data in biomedicine, of where the unmet medical needs are and how they can be addressed with these approaches, and of what the tractable next steps are that they can take to become innovators.

Additional program information and registration details are available on the conference website.

Previously: Mining data from patients’ charts to identify harmful drug reactions, Strength in numbers: Harnessing public gene data to answer a diverse range of research questions, Mining medical discoveries from a mountain of ones and zeroes, The data deluge: A report from Stanford Medicine magazine, Stanford’s Atul Butte discusses outsourcing research online at TEDMED and Health-care experts discuss opportunities and challenges of mining ‘big data’ in health care
Photo by Dwight Eschliman

Recognizing the value of mobile devices in conducting public health research, the Centers for Disease Control and Prevention has launched a project to examine the feasibility of collecting data using smartphone-based surveys and text messages. A recent post on Mobihealthnews offers more details:

The groups aim to first send the surveys to US residents aged 18 to 65 nationwide with questions related to smoking habits and alcohol consumption. Following the survey, the smartphone users will be asked to participate via text message in the feasibility study, which includes a survey immediately following the first and then another one a week later. The texts will include links to the survey on a mobile-friendly site.

Some of those who participate in the initial outreach that are non-smartphone users will be asked to participate in another study, the text message pilot, which will conduct the surveys one question at a time via text.

The study aims to evaluate, among other things, the response bias of data collected from the smartphone users on the mobile site to those responses collected via text.

Previously: Survey shows more than a quarter of American adults are mobile health users and CDC binge-drinking study demonstrates cell phones’ value in research
Photo by Jhaymesisviphotography

Frustrated by inconclusive tests, strange symptoms and a lack of answers from their health-care providers, some patients have turned to the online community for answers about perplexing illnesses. And a new web-based tool, called CrowdMed, aims to make it even easier to diagnose medical mysteries. The New Scientist reports:

Anyone can join CrowdMed and analyze cases, regardless of their background or training. Participants are given points that they can then use to bet on the correct diagnosis from lists of suggestions. This creates a prediction market, with diagnoses falling and rising in value based on their popularity, like stocks in a stock market. Algorithms then calculate the probability that each diagnosis will be correct.

In 20 initial test cases, around 700 participants identified each of the mystery diseases as one of their top three suggestions.

…

The goal is to help people who come down with any of around 7000 “rare diseases” as defined by health agencies in Europe and the US. In Europe alone, 30 million people have a rare disease, 40 per cent of whom either go undiagnosed or are misdiagnosed at some point.

As the popularity of using the Internet to answer health questions grows, it will be interesting to see how services such as CrowdMed, and search engines like FindZebra, even further redefine the doctor-patient relationship.

Previously: The importance of curation and communities when crowdsourcing clinical questions, New search engine designed to help physicians and the public in diagnosing rare diseases, Report shows 35 percent of U.S. adults turn to the Internet to diagnose a medical condition, Dr. Google: Threat or menace? and Patient self-diagnosis: From the browser to the exam room
Photo by Ryan Brooks